Provider Demographics
NPI:1497260186
Name:TEACHOUT, JESSICA DANIELLE (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:TEACHOUT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:DANIELLE
Other - Last Name:TEACHOUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:520 LUNALILO HOME RD UNIT 7414
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-1754
Mailing Address - Country:US
Mailing Address - Phone:808-348-5128
Mailing Address - Fax:
Practice Address - Street 1:4100 GOSS RD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35809-0001
Practice Address - Country:US
Practice Address - Phone:808-348-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1124133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1515034532OtherDEPARTMENT OF DEFENSE IDENTIFICATION NUMBER